“EMS” in the
New Healthcare Environment
© 2015 MedStar Mobile Healthcare
About MedStar…
• Governmental agency (PUM) serving Ft. Worth and 14 Cities
– Self-Operated
– 980,000 residents, 421 Sq. miles
– Exclusive provider - emergency and non emergency
• 125,000 responses annually
• 450 employees
• $37.5 million budget
– No tax subsidy
• Fully deployed system status management
• Medical Control from 14 member Emergency Physician’s
Advisory Board (EPAB)
– Physician Medical Directors from all emergency
departments in service area + 5 Tarrant County Medical
Society reps
Frenetic Change
The all-cause 30-day hospital readmission rate among Medicare fee-for-service
beneficiaries plummeted further to approximately 17.5 percent in 2013,
translating into an estimated 150,000 fewer hospital readmissions between
January 2012 and December 2013.
This represents an 8 percent reduction in the Medicare fee-for service all-cause
30-day readmissions rate.
http://innovation.cms.gov/Files/reports/patient-safety-results.pdf
Readmission reduction: A losing battle?
October 16, 2014
Readmissions may be "beyond a hospital's control," according to a
new study published in the American Journal of Managed Care.
They gave half the patients an intervention featuring pre-discharge
education and planning, post-discharge follow-up, an available
hotline and "bridging" techniques such as daily symptom checks.
Linden and his coauthor, Susan W. Butterworth, Ph.D., found no
statistical difference in readmissions between the two groups after
both 30-day and 90-day periods, although mortality was lower in
the intervention group than the control group.
http://www.ajmc.com/publications/issue/2014/2014-vol20-n10/acomprehensive-hospital-based-intervention-to-reduce-readmissionsfor-chronically-ill-patients-a-randomized-controlled-trial/3
The research found only a single instance where a patient received same-day
care from a PCP, and in that case the issue was dealt with without requiring
emergency care. Linden and Butterworth cited several cases in which patients
sought an appointment with their PCPs for non-emergency conditions but
were sent to the emergency room or unable to make an appointment for
weeks.
To enhance the innovative nature of the intervention, 2 post discharge
components were added—motivational interviewing–based health coaching
(MI) and symptom monitoring using interactive voice response (IVR). MI is a
standardized, evidence-based health coaching approach described as a
“collaborative, goal-oriented style of communication with particular attention
to the language of change.”
Although the Transitional Care Model sometimes includes home visits, we did
not include this in the intervention due to funding constraints and the lack of
evidence that it is a compelling component.
Take-Away Points from the Research:
• Our results suggest the need to continue experimenting with new
interventions targeting readmissions, especially for severely ill patients.
• Our addition of interactive voice response and motivational interviewing–
based health coaching to the transitional care model did not improve
outcomes.
• Our findings suggest that correcting improper use of the inhaler and
increasing adherence to inhaled medications may reduce 90-day mortality
for chronic obstructive pulmonary disease patients.
• Hospitals, without collaborative relationships with community-based
providers, may have limited ability to reduce readmissions, as they cannot
ensure timely and continuous care for patients after discharge.
• A challenging road lies ahead for stand-alone community hospitals seeking
to decrease readmissions and avoid financial penalties.
How house calls can cut down on hospital readmissions
The Valley Hospital in New Jersey sends medical teams to patients' homes to coordinate
follow-up care
By Leslie Small
April 23, 2015
The healthcare industry abounds with new ideas to reduce unplanned hospital readmissions
and emergency department (ED) visits, but a New Jersey hospital has turned to a seemingly
old-fashioned medical strategy--the house call.
The Valley Hospital in Ridgewood, New Jersey, launched its Mobile Integrated Healthcare
Program in August 2014 to provide "proactive, post-discharge home check-ups" to
patients with cardiopulmonary disease who are at high risk for readmission and either
declined or didn't qualify for home care services, according to a statement from the
hospital.
In the program, a team composed of a paramedic, an emergency medical technician and a
critical care nurse conducts a physical exam of the patient, offers medication education,
reinforces discharge instructions, completes a safety survey of the patient's home and
confirms that the patient has made a follow-up appointment with a physician.
http://www.fiercehealthcare.com/story/how-house-calls-can-cutdown-hospital-readmissions/2015-04-23
Hospitals' Goal: Empty Beds
08.21.15 by Bill Santamour H&HN Editor
“IF OUR BEDS ARE FILLED, IT MEANS WE’VE FAILED.”
That’s the striking message in an ad I came across for Mount Sinai Hospital, and it could
speak for hospitals across the nation as they transform from being strictly providers of
care to promoters of health. The ad does a good job of explaining in lay terms how the
new focus on population health management means that “instead of receiving care
that’s isolated and intermittent, patients receive care that’s continuous and coordinated,
much of it outside the traditional hospital setting.”
It spotlights Mount Sinai’s “tremendous emphasis on wellness programs”; its Mobile
Acute Care Team, which treats patients at home for certain conditions that otherwise
would land them in the hospital; and its Preventable Admissions Care Team aimed at
averting readmissions by providing both medical care and help with nonmedical factors
that impact health and access to care, like housing and literacy.
Not a lot there that hospital leaders don’t already know, of course, but you’ve got to
admit, the headline’s a grabber.
http://www.hhnmag.com/Daily/2015/August/weekly-reading-icd10mcdonalds-xenotransplants-blog-santamour?
ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Project Title: "Bundled Payment for Mobile Acute Care Team Services"
Geographic Reach: New York
Estimated Funding Amount: $9,619,517
Summary:
The Icahn School of Medicine at Mount Sinai project will test Mobile Acute Care Team
(MACT) Services, which will utilize the expertise of multiple providers and services already
in existence in most parts of the United States but will transform their roles to address
acute care needs in an outpatient setting. MACT is based on the hospital-at-home model,
which has proven successful in a variety of settings. MACT will treat patients requiring
hospital admission for selected conditions at home. The core MACT team will involve
physicians, nurse practitioners, registered nurses, social work, community paramedics,
care coaches, physical therapy, occupational therapy and speech therapy, and home
health aides. The core MACT team will provide essential ancillary services such as
community-based radiology, lab services (including point of care testing), nursing
services, durable medical equipment, pharmacy and infusion services, telemedicine, and
interdisciplinary post-acute care services for 30 days after admission. After 30 days, the
team will ensure a safe transition back to community providers and provide referrals to
appropriate services.
http://innovation.cms.gov/initiatives/Participant/Health-CareInnovation-Awards-Round-Two/Icahn-School-Of-Medicine-AtMount-Sinai.html
Name
City
CP MEDICAL CTR-DAVIES HOSP
CP MEDICAL CTR-PACIFIC HOSP
CHINESE HOSPITAL
KAISER FOUNDATION SAN FRAN
SAINT FRANCIS MEMORIAL HOSPITAL
SAN FRANCISCO GENERAL HOSPITAL
ST MARY'S MEDICAL CENTER
UCSF MEDICAL CENTER
ST ROSE HOSPITAL
LODI MEMORIAL HOSPITAL
EL CAMINO HOSPITAL
MILLS-PENINSULA MEDICAL CENTER
SAN FRAN
SAN FRAN
SAN FRAN
SAN FRAN
SAN FRAN
SAN FRAN
SAN FRAN
SAN FRAN
HAYWARD
LODI
MOUNTAIN VIEW
BURLINGAME
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
FY2013
FY2014
FY2015
FY2016
Readmission Readmission Readmission Readmission
Penalty
Penalty
Penalty
Penalty
0.05%
0.27%
0.55%
0.00%
0.18%
0.15%
0.15%
0.10%
0.55%
0.08%
0.00%
0.18%
0.01%
0.00%
0.51%
0.00%
0.42%
0.25%
0.03%
0.02%
0.58%
0.06%
0.00%
0.06%
0.01%
0.01%
2.16%
0.06%
0.53%
0.24%
0.16%
0.23%
1.06%
0.10%
0.43%
0.00%
0.00%
0.17%
2.12%
0.00%
0.22%
0.34%
0.25%
0.34%
1.23%
0.35%
0.75%
0.02%
Name
BAYLOR ALL SAINTS
BAYLOR SURGICAL HOSPITAL
JPS HEALTH NETWORK
PLAZA MEDICAL CENTER
THR - FORT WORTH
THR - ALLIANCE
THR-SOUTHWEST
NORTH SHORE UNIVERSITY
DUKE HEALTH RALEIGH HOSPITAL
REX HOSPITAL
WAKEMED, RALEIGH CAMPUS
RENOWN REGIONAL
RENOWN SOUTH MEADOW
NORTHERN NEVADA MEDICAL CENTER
City
FORT WORTH
FORT WORTH
FORT WORTH
FORT WORTH
FORT WORTH
FORT WORTH
FORT WORTH
MANHASSET
RALEIGH
RALEIGH
RALEIGH
RENO
RENO
SPARKS
State
TX
TX
TX
TX
TX
TX
TX
NY
NC
NC
NC
NV
NV
NV
FY2013
FY2014
FY2015
FY2016
Readmission Readmission Readmission Readmission
Penalty
Penalty
Penalty
Penalty
0.00%
0.00%
0.08%
0.30%
0.59%
N/A
0.01%
1.00%
0.06%
0.15%
0.28%
0.31%
0.00%
0.04%
0.00%
0.00%
0.03%
0.12%
0.32%
N/A
0.00%
0.98%
0.00%
0.08%
0.42%
0.10%
0.00%
0.13%
0.00%
2.76%
0.03%
0.00%
0.19%
0.00%
0.01%
0.55%
1.43%
0.04%
0.38%
0.27%
0.12%
2.11%
0.00%
3.00%
0.08%
0.00%
0.11%
0.08%
0.08%
0.39%
1.10%
0.07%
0.00%
0.02%
0.10%
1.42%
Emergency
Medical
Services?
Conundrum…
• Misaligned Incentives
– Only paid to transport
– “EMS” is a transportation benefit
– NOT a medical benefit
Our Role?
“Emergency medical services (EMS) of the future will be communitybased health management that is fully integrated with the overall
health care system. It will have the ability to identify and modify
illness and injury risks, provide acute illness and injury care and
follow-up, and contribute to the treatment of chronic conditions
and community health monitoring. This new entity will be
developed from redistribution of existing health care resources and
will be integrated with other health care providers and public health
and public safety agencies. It will improve community health and
result in more appropriate use of acute health care resources. EMS
will remain the public’s emergency medical safety net.”
•
•
•
•
•
•
•
EMS Loyalty Program
System Abusers
9-1-1 Nurse Triage
CHF/High Risk Dx Readmissions
Observational Admission Avoidance
Hospice Revocation Avoidance
Home Health Partnership
Patient Navigation vs. Primary Care
•
•
•
•
•
•
•
EMS Loyalty Program
System Abusers
9-1-1 Nurse Triage
CHF/High Risk Dx Readmissions
Observational Admission Avoidance
Hospice Revocation Avoidance
Home Health Partnership
Patient Navigation vs. Primary Care
Texas is ‘Different’
Readmission Avoidance
• At-Risk for readmission
– Referred by cardiac case managers
– Routine home visits
• In-home education!
• Overall assessment, vital signs, weights, ‘environment’
check, baseline 12L ECG, diet compliance, med
compliance
• Feedback to primary care physician (PCP)
– Non-emergency access number for episodic care
– Decompensating?
• Refer to PCP early
• In-home diuresis
The Real Benefits:
“Before I started this program I was sick
every day; I was going to the emergency
room nearly every day.”
“I have learned more in the last three
months from John and you than I have
ever learned from the doctors, the
hospitals, or the emergency rooms.”
“Since this program, I have not had any
pain medicines and have not been to the
emergency room. I am keeping up with
my doctor’s appointment and my MHMR
Antoine Hall, MIH/CHP Patient
appointments.”
Enrolled 11/20 – 12/29/13
Used by special permission from Antoine Hall
Antoine Analysis
Ambulance Transports
ED Visits
Inpatient Admissions
Before
11
12
4
MIH Visits
MIH Visit Expenditure per Contact
MIH System Costs
Healthcare System Savings
After
0
0
0
Change
-11
-12
-4
Avg. Payment Expenditure Savings
$427
($4,697)
$774
($9,288)
$9,203
($36,812)
22
$75
$1,650
($49,147)
1115 Waiver
• Partnership with John Peter Smith Health
Network to expand:
– Readmission Prevention
– 9-1-1 Nurse Triage
– High Utilizer Group
– Obs Admit Avoidance
Readmit Program Analysis
June 2012 - June 2015 JPS & THR Combined
Patient Enrollments (1, 3)119
Count
Rate
Rate Reduction (2)
Expenditure per Admission (4)
Admissions Avoided
Expenditure Savings
Admission Savings Per Patient
30 Day ED Visits
43
36.1%
63.9%
30 Day Admissions
33
27.7%
72.3%
$
$
$
10,500
86
(903,000)
(7,588)
Notes:
1. Patient enrollment criteria requires a prior 30-day readmission and the
referral source expects the patient to have a 30-day readmission
2. Compared to the anticipated 100% readmission rate
3. Enrollment Period at least 30 days and less than 90 days
4. http://www.hcup-us.ahrq.gov/reports/projections/2013-01.pdf
Patient Self-Assessment of Health Status (1)
As of:6/30/2015
High Utilizer Group
Enrollment Graduation
Change
Sample Size
55
Mobility (2)
2.33
2.55
9.4%
Self-Care (2)
2.65
2.82
6.4%
Readmission Avoidance
Enrollment
Graduation
Change
41
2.37
2.41
1.7%
2.54
2.76
8.7%
Perform Usual Activities (2)
Pain and Discomfort (2)
Axiety/Depression (2)
2.24
1.98
2.11
2.58
2.52
2.51
15.2%
27.3%
19.0%
2.27
2.44
2.32
2.51
2.68
2.63
10.6%
9.8%
13.4%
Overall Health Status (3)
5.18
6.85
32.2%
4.88
6.78
38.9%
Notes:
1. Average scores of pre and post enrollment data from EuroQol EQ-5D-3L Assessment Questionaire
2. Score 1 - 3 with 3 most favorable
3. Score 1 - 10 with 10 most favorable
Mobile Healthcare Programs
Patient Experience Summary
Through June 30, 2015
Program
Medic Listened?
Time to answer your questions?
Overall amount of time spent with you?
Explain things in a way you could understand?
Instructions regarding medication/follow-up care?
Thoroughness of the examination?
Advice to stay healthy?
Quality of the medical care/evaluation?
Level of Compassion
Overall satisfaction
Recommend the service to others?
HUG
4.98
4.96
4.98
4.98
4.98
4.96
4.96
4.98
4.98
4.92
97.8%
CHF
4.86
4.86
4.86
4.92
4.82
4.84
4.92
4.85
4.85
4.85
100.0%
Overall Avg
4.92
4.91
4.92
4.95
4.90
4.90
4.94
4.92
4.92
4.89
98.9%
Select Comments:
​Client states ''You care more about my health than I do."
"​Keep the same compassionate, excellent people you have working for you now and your service
will continue to be great! Everything was perfect, a 10!"
​"yall have been off the charts helpful" "no complaints" "glad the hospital got it going for me"
​"Thank you very much! We couldnt have done this without you!"
"The medics spent lots of time with me and provided very useful information. I really loved the
program. They were very friendly and did an awesome job."
​"I love y'all, wonderful, Y'all 2 have been really big help and great with patience with me even
though I'm a hard headed lil ol lady."
Home Health Issues
• Instantly penalized for readmissions
– No more hospital referrals
– CMS Penalties for home health coming
• High cost of night/weekend demand services
• Don’t know when their patients call 911
– Consult to < admission
Home Health Partnership
Home Health
Care Coordination Examples
Client: XXXX, Oscar A – 19XX-12-18
Status: Active
Visit Date: 6/15/2015
Visit Acuity: Unscheduled Visit
Transport Resource: N/A
Note By: Tim Gattis
Program: Home Health
Referring Source: Klarus
Visit Type: Home Visit
Visit Outcome: AMA
Response Number: 150615012
Note:
AOSTF 28 yo male sitting on couch. He states that he is SOB, his abdomen is distended and his
legs are swollen all of this since 2000 this evening. He also reports his pump was alarming starting
at 2100 and he shut it off.
Pt. requires Milrinone continuous infusion and the pump was reading a high pressure alarm. Pt.
also reports a cough this evening. In reviewing his HX he has CHF with an EF of 20-25% and CKD.
He reports he feels like he always does when he gets fluid overloaded. Pt. also reports a 4 lb.
weight gain in the last 24 hrs. Upon exam noted pt. in mild -moderate resp. distress with SPO2 in
the 80's off his O2. In reviewing some old notes he does not like to wear his O2. Pt. is A&OX4,
PPTE, MAE. Pt. is mildly tachycardic, BS clear upper and crackles in bases. ST on 12-lead W/O
elevation.
Abdomen appears distended though I have never seen this pt. in the past. Pt. has 3+ edema in
lower ext. PICC line port being used for Milrinone infusion was occluded. PICC was flushed and
infusion resumed. Chem 8 was obtained. NA 133, K+ 3.7, Cl 97, CA 1.19, Tco2 36, Glucose 143,
BUN 38, Cre 1.3, Hct 40, Hgb 13.6A Gap 5. Pt. was given Lasix 80mg SIVP and advised to double
his morning potassium dose. The importance of wearing his O2 was again stressed. I discussed
the plan with pt. to ensure he felt capable of staying at home and that was his preference.
Pt. stated he had a urinal and was advised to use it and write down all of his output between now
and when he sees the nurse. He was advised to call back for any issues or worsening of condition.
I also spoke with Sean at Klarus and he is good with plan. Klarus will follow up tomorrow with
client. Pt. declined transport and AMA was signed. ​
Client: XXXX, Clara L - 1934-03-06
Visit Date: 8/21/2015
Visit Acuity: 911 Call
Response Number: 150821007
Program: Home Health - 911
Visit Type: Home Visit
Transport Resource: N/A
Note By: Ronald Moren
Family called 911 and stated pts BGL was 29. On EMS arrival, family had managed to give pt a few
mouthfuls of honey and BGL was 32. Pt found lying in bed pt is alert to painful stimuli only. Pt is
atraumatic. BBS are clear, =, bilateral with good chest rise and fall. Abd is soft and non-tender with no
masses noted. Pt has a PICC line in right arm that she receives daily antibiotics from family through.
PICC line was accessed and approx 7 ml fluid withdrawn. IV D-10 was started and 250 ml was
infused. Pt became A&OX4 and BGL increased to 188. Pts daughter cooked her some eggs and gave
her an ensure to drink.
Pt states she feels much better and does not want to go to the ER at this time. It was explained to the
patient and her family that a large decrease in blood sugar, while may be expected, should still be
evaluated by a physician. Pt and family still did not want to go to the ER. Pt and family were educated
on possible problems with low BGL including falls, syncope, AMS, & seizures. Family was instructed
to monitor blood glucose levels and to contact KLARUS and/or her PCP in the morning. Family was
also instructed to call 911 again if pts condition changes.
KLARUS was contacted and message left, RN (Diane) called back and confirmed message received
and advised she would have somebody go out and see patient in the morning.
Client: XXXXX, Joycia Y – 19XX-XX-XX
Referring Source: Klarus
Visit Type: Home Visit
Program: Home Health - 911
Visit Date: 4/11/2015
Visit Acuity: 911 Call
AOSTF pt. lying on couch in NAD. Crew reports pt. has been having CP since last night and
is mid sternal and radiates to her back, rates at 9/10. Her pain is worsened by movement
and breathing.
Her V/S are reported to be stable and she is reported to be a little anxious. In speaking with
the pt. she agrees with the crews report of the situation. She also reports she has had a
10lb weight gain since yesterday according to her Cardiocom unit.
She has had this in the past and this is the same pain she usually has. She believes her
NTG will relieve it but she was afraid to take as Klarus usually walks her through it. She
also has an anxiety history and has not taken her Xanax or other morning meds yet. Pt.
denies any N/V or diaphoresis.
She also feels like her hands and feet are swollen as they feel tight. She denies
additional complaint. Upon exam noted pt. in NAD. Pt. is A&OX4, PPTE, MAE.
VSS. BSCB, non labored. SR on 12-lead w/o acute changes. No edema is noted to
hands and very mild edema noted to top of her feet once socks removed. I spoke
with Diana at Klarus regarding this pt. I reported her complaints. I did advise her
about the weight gain. She felt pt. should take her NTG. She also reports pt. has
been to the hospital for this in the past and was ruled Anxiety those times.
Pt. reported dramatic improvement in the discomfort after the NTG. Pt. was
advised we could not R/O cardiac involvement without blood work but pointed
out what we found on exam. Pt. opted to take her morning meds and stay at
home.
As we were getting ready to leave Diana called back and reported her weight
had in fact increased by 10 lbs. over the last 24 hours and would like her to be
diuresed. I relayed this to the pt. and she agrees to plan.
A Chem 8 was obtained and her K+, Hct and Hgb was noted to be low.
I spoke with Dr. Davis regarding the Potassium dosing since she was a little
low and he advises to increase her Potassium from 40 mEq Bid to 40mEq Tid
today only.
IV was initiated and Lasix 100mg IV was given SIVP. Pt. was advised to
monitor and record her urine output using the hat she was provided and we
would see her at 1400 for a F/U. If anything changes to call Klarus or us back.
Pt. remains pain free upon departure.
I again spoke with Diana and advised of the treatment and that she would
need a visit from them within 24 hrs. by protocol and she was going to get that
set up. Visit complete.
Utilization Outcome Summary
Home Health Partnership
Enrollments by Home Health Agency
9-1-1 calls by Enrolled Patients
9-1-1 Calls by Enrolled Patients with a CCP on-scene
ED Transports when CCP on Scene
Home Visits Requested by Agency
ED Transports from home visits requested by Agency
As of:Jul-15
#
754
455
200
74
158
6
%
100.0%
60.3%
44.0%
37.0%
21.0%
3.8%
“Mobile Integrated Healthcare is an
innovative and patient-centered approach
to meeting the needs of patients and their
families. The model does require you to
“flip” your thinking about almost everything
– from roles for health care providers, to
what an EMT or paramedic might do to care
for a patient in their home, to how we will
get paid for care in the future.
The authors teach us how to flip our thinking
about using home visits to assess safety and
health. They encourage us to segment
patients and design new ways to relate to
and support these patients. And they urge
us to use all of the assets in a community to
get to better care. This is our shared
professional challenge, and it will take new
models, new relationships, and new skills.”
Maureen Bisognano
President and CEO
Institute for Healthcare Improvement
2009 = 4 Programs
2014 = 160 Programs
Paramedics Aren't Just for Emergencies
Home visits for lab tests, IV medications and hospital follow-up
By Laura Landro
Aug. 17, 2015
Paramedics, who race to emergencies and transport victims to the nearest ER, are taking on a new
role: keeping patients out of the hospital.
In this new role, paramedics augment existing programs like visiting nurse services and home care.
They also treat patients who don’t meet home-nursing criteria or don’t want someone in their
home all the time but still have complex needs, says David Schoenwetter, an emergency
physician and head of the mobile health paramedic pilot program at Geisinger Wyoming Valley
Medical Center in Wilkes-Barre, Pa., part of Danville, Pa.-based Geisinger Health System.
The programs aim to reduce the high costs of emergency room visits and inpatient hospital stays.
Hospitals are facing financial penalties from Medicare and other payers when patients are
readmitted to the hospital within 30 days of being discharged.
days among 704 patients who had a home visit from a paramedic, Geisinger calculates. In tFrom
March 2014 to June 2015, the Geisinger mobile health team prevented 42 hospitalizations, 33
emergency department visits and 168 inpatient he case of heart-failure patients, hospital
admissions and emergency-room visits were reduced by 50%, and the rate of hospital readmissions
within 30 days fell by 15%. Patient satisfaction scores for the program were 100%.
http://www.wsj.com/articles/paramedics-aren-t-just-foremergencies-1439832074
Change From the Inside Out –
Health Care Leaders Taking the Helm
Donald M. Berwick, MD, MPP1; Derek Feeley, DBA1; Saranya Loehrer, MD, MPH1
1Institute for Healthcare Improvement, Cambridge, Massachusetts
JAMA. March 26, 2015.
doi:10.1001/jama.2015.2830
Even as politicians and pundits continue to debate the merits of the Affordable Care Act
(ACA), it is time to look beyond it to the next phase of US health care reform.
innovations in delivery mature at a far faster pace than laws and regulations evolve,
even in far less contentious political times than today’s. For example, productive new
health care roles, such as community paramedics, community health workers, and
resilience counselors, emerge at a rate that legal requirements and reimbursement
policies simply do not match.
http://jama.jamanetwork.com/article.aspx?articleid=2210910